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Benjamin Franklin once said, “Life's tragedy is that we get old too soon and wise too late.” While there is substantial wisdom in that statement, I can think of at least one exception that might set old Ben on his rear, or is it ear? It is hard to believe that 20 years have passed since the first edition of Vestibular Rehabilitation was published. Yet even at its birth there was considerable wisdom in its words. At that time the responsibility for evaluating and rehabilitating patients presenting with dizziness and vestibular compromise was restricted to a select few, and this area of rehabilitation had not emerged as a specialty. Susan Herdman recognized a need to train rehabilitation clinicians to better understand and treat the postural compromise generated through visual deficits, headache or other maladies that would adversely impact the quality of life of those unfortunate enough to have acquired vestibular pathologies. The extent to which this knowledge has grown over these two decades and with it, the interest of students and clinicians is truly extraordinary. Throughout this time Vestibular Rehabilitation has remained the “go to” text for specialists in this area while also serving as a critical reference source for all neurorehabilitationists.

All contributors to the Contemporary Perspectives in Rehabilitation series have always prided themselves on maintaining the infrastructural integrity of its foundation ....... evidence based referencing, problem solving presentations and the latest and most novel data or treatment techniques. Vestibular Rehabilitation continues to adhere to these principles and undoubtedly the result has been a steadfast allegiance to its content from amongst its followers ....... teachers, clinicians and students. The fact that the content has been updated consistently at 5 year intervals speaks to the dedication shown by its contributing authors, many of whom have persisted through several editions. Throughout this time, Dr. Herdman has amassed a larger international cohort of knowledgeable clinicians, many of whom have come to assist her in what arguably might be called the most popular (and intense) vestibular rehabilitation course in the United States, if not the world. Many of those once considered novices are now positioned to disseminate information themselves. Undoubtedly, Dr. Herdman has assembled the next generation of contributors. Amongst the 34 individuals whose collective efforts define the 4th edition of Vestibular Rehabilitation, 14 are first timers and all possess the skill and knowledge to become persistent contributors to subsequent editions. As one reads Chapters 3 (Laurie King), 6 (Anne Galgon), 7 (Natalia Ricci), 13 (Steve Benton), 14 (Rosalyn Schneider), 17 (Yew Ming Chan), 19 (Jeffrey Staab), 20 (Jeff Hoder), 24 (Jennifer Braswell Christy), 26 (Laura Morris and Kim Gottshall), 28 (Courtney Hall and Dara Meldrum) and 30 (Lisa Heusel-Gillig and Courtney Hall), please know that while these individuals might not be the sole author of those respective contributions, their effort to revise previous content was substantial and the resulting quality of their work is outstanding.

In this edition, all chapters have been updated and new cases permeate the management chapters to illustrate how patients with specific problems are treated. The thought-provoking and problem solving nature of the clinical chapters are supported by the necessity to foster evidence based references, a fundamental tenet of all volumes in the Contemporary Perspectives in Rehabilitation series. While the 3rd edition of Vestibular Rehabilitation was accompanied by 68 videos, this edition has over 100. The videos include normal and abnormal eye movements, assessment procedures, demonstrations of some exercises, and gait assessments. Chapters emphasizing tinnitus, novel approaches in the assessment and treatment of anterior and horizontal canal benign paroxysmal positional vertigo (BPPV), and data on outcomes in patients with unilateral and bilateral vestibular hypofunction are distinctly new to the 4th edition. The management of patients with chronic subjective dizziness represents another addition to the text. These are patients who present with chronic dizziness and motion sensitivity that often is accompanied by variable amounts of anxiety and phobic behavior.

The text has been further contemporized through the addition of a chapter on the management of patients with vestibular problems precipitated from head trauma including etiologies from post-concussion syndrome caused by blast injuries. Regrettably there is ample reason to believe that the incidence of this problem may be profoundly underestimated. If so, then this category of patient will present unique challenges to vestibular rehabilitation clinicians and the treatment components may well incorporate a need to foster compliance because of concomitant behavioral changes. Additional information is contained in information regarding emerging technologies for the treatment of patients with vestibular disorders. Such rehabilitation includes novel biofeedback alternatives, use of virtual reality and gaming, such as the Wii. These advances, while challenging, provoke opportunities to discover and implement new approaches towards enlisting functional plasticity to achieve enhanced quality of life. We can be rest assured that advances in technologies and devices will continue to make their way into the armamentarium of tools to restore optimal balance, reduce dizziness or improve the consequences of migraine, as examples.

The contributions from vestibular neurorehabilitation therapists and specialty physicians are woven along a highly integrated network. Over each edition, the blend of input from these specialists becomes more tightly coupled. This fluidity may go unrecognized by students, but suffice to say, there are very few courses, let alone text books, in which the content amongst different specialists, both physician and non-physician, can be assembled and transmitted so smoothly. Herein rests an opportunity to learn from a panel of experts who would be very difficult to assemble collectively. As I concluded in a previous Foreword, the sum of these parts is truly greater than its whole.........